Patients become people through the social history

One day in clinic, recently, I reviewed my daily schedule with the oncology fellows who were working with me that day. With the exception of the new patients on my schedule, I recognized all of the names on my list. I opened the electronic chart of the first patient to skim the problem list, a handy spot where I keep a summary of all the treatments received for the cancer diagnosis.

“Mrs. Jordan (name and details changed) is just here for routine follow-up. She completed therapy about three years ago, and she’s done great so far,” I said. I went on to tell them that her son was a physician, but that he never came with her to her appointments. He had emailed, once, just to touch base; but it was clear that his mother valued her independence and wanted be in charge of her own health care. She was in her 80s and very clear about her expectations of me and, I’m certain, of her son.

Using the computer mouse, I pointed to another patient on the list.

“Ms. Finley is coming today to discuss her CT scan from last week,” I said.

I planned to discuss chemotherapy with Ms. Finley, and I was sure she would agree based on the scan results that showed progression of her cancer. I mentioned the regimens I was considering to the fellows, as well as my rationale for my top two choices. I fielded questions about chemotherapy selection in platinum-resistant ovarian cancer versus platinum-sensitive disease.

“She’s retired from teaching,” I told the fellows. “She usually comes with her daughter, who’s a pharmacist.” Keeping busy through volunteer work has been very important to Ms. Finley, and it’s helped to reduce her anxiety about her disease. I hoped she was still doing it. If she had stopped volunteering, it could be an indication of her level of symptoms.

I shifted the mouse and hovered the pointer over the next patient.

“This one is coming for routine follow-up,” I said. “She’s usually doing great, except for some arthritis issues. She hasn’t needed treatment for her lymphoma yet. We always talk cooking and food.”

“Ms. Richardson loves good olive oil,” I told the fellows. Ms. Richardson had given me tips on where to buy specialty olive oil locally, and she’s told me how she uses flavored olive oil in her own cooking. She cooks with her grandchildren, and the ability to do this when they visit her means so much to her.

I continued on with my introductions of the day’s patients to the oncology fellows, including a bit about the various diagnoses and treatments and rationale for treatment selection, but even more about who the patient is as a person: what they enjoy, who comes with them to their visits, how they cope with their diagnosis, the type of support they have at home. The information I was giving, I realized, was the social history.

When I was a medical student, I remember learning the value of the social history in discovering unhealthy habits—such as alcohol use, tobacco use, illicit drug use, or a sedentary lifestyle. I learned that the information elicited from a patient during the social history might give insight to the patient’s overall well-being, their coping strategies, and their potential for health risks in the future. As a student, I dutifully made note of my patients’ work history, occupational exposure to chemicals, number and type of pets in the home, amount of caffeine intake, exercise habits, seatbelt use, and hobbies. And while my internal medicine attendings seemed to appreciate my thoroughness, my lengthy social history during patient presentations surely evoked some eye rolls from the residents and faculty on my surgery rotations.

Though I once did it because it was a required part of the medical history, the social history has become one of my favorite things about patient care. It is through the social history that I really get to know who my patient is as a person, beyond the label of the cancer diagnosis. Through the social history, I get to know details about my patient’s life that help me to provide more thoughtful care, more humanistic care.

It is through the social history that my patients become more than just patients with a cancer diagnosis. They become people.

Patients become people through the social history 8 comments

The social history, aka knowing the patient and not just the disease, is dying along with the doctor-patient relationship. Assembly-line medicine has no time for it, nor is there continuity in the relationship to make it worthwhile. Patients themselves are wary of disclosing personal details that are not obviously relevant to diagnosis, for incorporation into an impersonal EHR database.

Much is being lost. Many hobbies, lifestyle factors, etc can be relevant to health in non-obvious ways. Patients don’t necessarily know this ahead of time. Time-pressure on doctors (and anyone else) forces a tunnel vision where it’s harder to appreciate the big picture, or consider less likely possibilities. The patient as person is lost in the equation.

Ladyimacbeth

Yeah, the EMR has made me a lot more tight lipped. Many are using the free EMRs that sell our data to the highest bidder. Not very comforting to know.

SarahJ89

I stopped talking when the computer showed up.

Ladyimacbeth

Yeah, my level of disclosure depends upon if there’s a paper medical record or EMR. I disclose most everything that’s asked with a paper record, and I withhold sensitive data with an EMR. My concern is not just the fact that our medical data is sold, it’s the continual data breaches that occur with EMRs. Privacy is no more.

If the one physician I have who still uses a paper record moves to an EMR, I guess I will be screwed.

Suzi Q 38

I highly respect and enjoy physicians who attempt to do this…learn as much as they can about their patients.

I just think that times have changed, and I fully understand why there is simply little or no time for such niceties.
I know that with every minute of social talk, the later my doctor is getting with his next patient.

crnp2001

I think getting a good social (personal) history & getting to know the in-and-outs of patients is ESSENTIAL to building trust and a true relationship. Yes, I understand people hesitate to give information to the almighty EMR. However, I cannot tell you how many hundreds of patients have told me that my acknowledging their personal side is CRUCIAL to our patient/provider relationship. They feel valued. Respected. Yes, it takes time to build this…and sometimes addressing the social aspects will make me run late. But it makes the patient feel good. And yes, me too. It’s one of the only things left in primary care to give meaning to what we do.